A nurse is reinforcing teaching with an assistive personnel (AP) about a client who has pertussis. Which of the following instructions should the nurse include in the teaching?
Wear an N95 mask when in the client's room.
Wear a gown when caring for the client.
Wear a simple face mask when caring for the client.
Place the client in a negative air pressure room.
None
None
The Correct Answer is C
Choice A reason: This is a requirement for Airborne Precautions (used for smaller particles like those in Tuberculosis, Measles, or Varicella). Pertussis droplets are too large to remain suspended in the air, so a standard surgical mask is sufficient.
Choice B reason: Wearing a gown when caring for the client is not necessary, as pertussis is not transmitted by contact with body fluids or surfaces.
Choice C reason: Pertussis (Whooping Cough) is a highly contagious respiratory infection caused by the bacterium Bordetella pertussis. It is transmitted through large respiratory droplets expelled when an infected person coughs or sneezes. Because these droplets are heavy and typically travel only 3 to 6 feet before falling to the ground, Droplet Precautions are required.
Choice D reason: Placing the client in a negative air pressure room is not indicated, as pertussis is not classified as an airborne infection that requires isolation in a specially ventilated room.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Maintaining the client on bed rest is not an appropriate action, as it can increase the risk of thromboembolism, infection, or atelectasis after surgery. The nurse should encourage early ambulation and exercise as tolerated by the client.
Choice B reason: Decreasing the client's fluid intake is not an appropriate action, as it can cause dehydration, constipation, or impaired wound healing after surgery. The nurse should encourage adequate hydration and nutrition to promote recovery and drainage.
Choice C reason: Applying cold compresses to the site is not an appropriate action, as it can cause vasoconstriction, inflammation, or pain at the site. The nurse should apply warm compresses to the site to facilitate drainage and reduce swelling.
Choice D reason: Placing the right leg in a dependent position is an appropriate action, as it can promote gravity-assisted drainage from the site and prevent fluid accumulation or infection. The nurse should place the drain below the level of the wound and secure it to prevent dislodgment or tension.
Correct Answer is D
Explanation
Choice A reason: Shaving the client from axillae to groin is not necessary, as it has no relation to the procedure and can cause skin irritation or infection.
Choice B reason: Administering a cleansing enema is not required, as it does not affect the upper gastrointestinal tract that is examined by the procedure. The client should fast for at least 6 hours before the procedure to ensure an empty stomach.
Choice C reason: Having the client drink contrast medium is not indicated, as it can interfere with the visualization of the mucosa and lesions by the endoscope. The client may receive a local anesthetic spray or gargle to numb the throat and a sedative to relax and reduce discomfort during the procedure.
Choice D reason: Ensuring the signed consent is in the medical record is an essential action, as it indicates that the client has been informed about the purpose, risks, benefits, and alternatives of the procedure and has agreed to undergo it voluntarily.
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